Hyperbaric oxygen in the prevention of osteoradionecrosis of the jaws

Abstract

Patients who have had their jaws irradiated as part of management of head and neck malignancy are at risk of osteoradionecrosis (ORN) following tooth extraction. Thirty-seven patients with a history of irradiation to the jaws were managed during a four year period. Twenty-nine patients received hyperbaric oxygen therapy (HBO) consisting of 20 treatments before surgery and ten treatments a f t e r. Only one (4 per cent) developed ORN. Seven patients who did not have HBO and one who did (15 per cent) developed ORN. The need for prophylactic treatment with HBO is discussed. It is recommended that prophylactic HBO is used prior to surgery for irradiated facial bones.Key words: Osteoradionecrosis, hyperbaric oxygen, surgery.(Received for publication July 1998. Accepted September 1998.) i rr a d i ated bone, which fails to heal without intervention'.3 The usual first presentation is pain with subsequent exposure of bone into the mouth. This m ay progress to wide exposure of bone both i n t o the mouth and through the skin. M o r e advanced stages are associated with constant pain, s e q u e s t r at i o n , p at h o l o gic fracture, m a l o d o u r , deformity and discharge. 4 Radiology is not usually helpful in the early stages of ORN 5 and even in its advanced stages does not necessarily relate to the imaging features.6 Described r a d i o graphic features range from normal appearance, to localized areas of osteolysis to extensive osteolysis, sequestra and fracture. Extraction sockets will often remain visible for more than twelve months after surgery.Computerized tomography (CT) is more valuable in determining the boundaries between norm a l and non-viable bone.5 Nuclear medicine scans, usually with technetium 99, will delineate between vascularized and inflamed areas versus non-viable s e g m e n t s. 7 Magnetic resonance imaging has a limited role.Concepts of the pathogenesis of ORN have undergone change over the last decade. For much of this century ORN was considered primarily an infection,that is,the irradiated bone was injured and became infected. 8 Common traumatic events which breached the overlying mucosa and thus allowed ingress of bacteria were biopsies, cancer surgery, tooth extraction and denture irritation.Hence treatment of ORN followed the classical principles of infection management; removal of the cause, debridement, drainage and antibiotics.This concept was challenged by Marx in the early 1980s. He presented the view that ORN was p ri m a rily a non-healing wound secondary to endarteritis.1 The effect of irradiation on the bone Introduction Osteoradionecrosis (ORN) of the facial bones, particularly of the mandible, is a known serious complication of therapeutic radiotherapy for head and neck cancer. ORN is painful, debilitating and frequently refractory to treat m e n t .

A survey of antibiotic prescribing by maxillofacial consultants for dental extractions following radiotherapy to the oral cavity

“…When available and in cases where radiation dose to the mandible has been greater than 50 gray, prophylactic HBO should be considered. 30,36 Although the use of amoxicillin, metronidazole and clindamycin are choices which conform with recent recommendations 31 the duration of the course given varied from 3 to 28 days and on one occasion until healing had been completed (Table 1). Such action exposes the absence of a definitive oral health protocol for patients at risk of ORN.…”

“…Many authors of articles on ORN either failed to mention antibiotics at all, or made only a brief comment about their general application. 1,5,8,11,12,[28][29][30] The purpose of this investigation was to determine prescribing for exodontia and minor oral surgery following radiotherapy by surveying current opinion amongst consultant oral and maxillofacial surgeons.…”

Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies

“…In two non-randomized studies [11,12], a comparison was made between patients who did vs. those who did not receive preventive HBO prior to dental extractions. Together, these two studies demonstrated a similar prevalence of ORN with 1/36 (2.8%) in the HBO group and 3/107 (2.8%) in the non-HBO group.…”

Antibiotic prophylaxis for dentoalveolar surgery: is it indicated?

“…This may be prophylactically or therapeutically treated with hyperbaric oxygen. 47 Patients with bone diseases, treated with bisphosphonates, have recently been shown to be prone to a small risk of developing osteonecrosis. 48 This is initiated by extraction which should be avoided if possible.…”